Bone Health with Dr. John Neustadt: Rational Wellness Podcast 114
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Dr. John Neustadt discusses the Bone Health with Dr. Ben Weitz.
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Podcast Highlights
3:32 The reason we are having an epidemic of osteoporosis and osteopenia in the US is that we are getting older, according to Dr. Neustadt. This is largely with women since estrogen is anti-inflammatory and is protective of bone and estrogen levels drop after menopause. In fact, the first 10 years after menopause is the fastest period of bone loss for most women.
4:33 There is a recent study that indicates that men in their 30s and 40s also experience a significant loss of bone. (Bone Mineral Density Among Men and Women Aged 35 to 50 Years.) Dr Neustadt says that this study contradicts most other research that shows that 80% of adults with bone loss are women and that men are much less frequently affected. This new research is very alarming and what may be happening is that men and women both show some loss of bone in this younger age group, but thus far, all the research has focused on osteoporosis, whereas this study looked at osteopenia. Men are not normally screened for bone density at all. It might be that there is some loss of bone in both men and women and then after menopause, the loss accelerates in women. But when it comes to making recommendations, we should focus not just on bone density, but on fracture risk. If you fracture a hip, there’s up to a 40% chance that you’ll be dead within six months. If you happen to survive the first year, there’s a 20% chance that you’re going to end up in a nursing home and you’re going to suffer chronic pain or other complications from that fracture. A bone density test only predicts 44% of women who will break a bone and only 21% of men because fracture risk depends upon factors other than just bone density. Medications are a huge factor and proton pump inhibitors, like Protonix, Prilosec, and Zantac, were only approved by the FDA for short period of times, yet they are being prescribed or taken over the counter for years for acid reflux and other stomach pain. Research shows that after fours years of taking them the risk for a hip fracture increases by 60%. Another common medication, Prednisone, can strip minerals like calcium from bone and cause osteoporosis. Tamoxifen, taken by women after breast cancer surgery to prevent recurrence can also cause such bone loss. Diseases like Crohn’s disease, ulcerative colitis, and celiac disease can cause malabsorption of nutrients and these increase fracture risk. Autoimmune diseases, which result in increased systemic inflammation, are also risk factors for fracture risk. Sedentary lifestyle is a factor because if somebody doesn’t have balance and strength, then they’re more likely to fall and fracture. Poor diet is also a risk for fracture.
12:24 Fractures typically occur after someone loses their balance and falls. But pathological fractures can result from taking bisphosphonate medications like Fosamax and Zometa, which are the most prescribed medications for osteoporosis and osteopenia. Bisphosphonates have been shown to reduce fractures by 45%, but these are primarily spinal fractures, which are painful, but they do not typically kill you like the hip fractures. And these drugs have not been shown to prevent primary hip fractures. Bisphosphonates work by poisoning the osteoclasts, which are the cells in the bone that clear away old, junky bone. The bone remodeling process requires that the osteoclasts that clear away the old, used bone, and the osteoblasts that make the new bone, to be in balance. With bisphosphonates, you get more bone, but it tends to be an abnormal, weaker bone. This is why sometimes you get unusual fractures, like unicortical fractures of the femur, and while taking these medications these patients have a reduced ability to heal from such fractures.
15:51 While bone density tests are beneficial and do have some predictive value for fracture risk, they only measure the mineral content of the bone and not the quality or flexibility of the bone, which has more to do with fracture risk. The minerals give the bone its hardness. It’s the bone collagen, the connective tissue of the bone, that is not measured on the bone density test, that allows bones to have some flex and gives bones their ability to resist fractures. There are urinary markers for bone resorption, like N-Telopeptide (NTX) and the C-Terminal peptide (CTX), but there are no prospective studies showing that changing it improves fracture risk, so Dr. Neustadt doesn’t recommend these tests. You can measure undercarboxylated osteocalcin, which has been described as a marker for bone quality as well as a marker for vitamin K status and which some studies have shown is a good marker to predict hip fracture risk (Serum undercarboxylated osteocalcin is a marker of the risk of hip fracture in elderly women). But Dr. Neustadt explained that one study in rats showed that rats that did not produce osteocalcin actually had stronger bones, so he does not run this test.
20:13 Dr. Neustadt usually measures vitamin D in patients with osteopenia and osteoporosis but he does not usually measure vitamin K status. He likes a vitamin D level of above 60 ng/mL. There are only 4 nutrients that have been shown to significantly reduce fracture risk: vitamin D, calcium, a form of vitamin K known as MK-4, and strontium. Here is one paper showing that adding MK-4 to calcium reduced fractures by 60% compared with the calcium-only group, including a 54% decrease in vertebral fracture. Vitamin K2 (Menatetrenone) effectively prevents fractures and sustains lumbar bone mineral density in osteoporosis. Here is another review article on this: Vitamin K2 therapy for postmenopausal osteoporosis. Calcium and vitamin D have been shown to reduce fractures by about 20%. Strontium has been shown to reduce fracture risk by 45%, which is no better, no worse than Fosamax, but he usually does not recommend strontium initially. Dr. Neustadt recommends 45 mg per day of MK-4, along with appropriate amounts of vitamin D and calcium as first line therapy for his patients. He does not recommend MK-7 even though it has a longer half life in the body, because it has not been shown in studies to reduce fracture risk. MK-7 has been shown to promote arterial health and to help decalcify arteries. MK-4, unlike MK-7 seems to have some anti-cancer effects and is being used in phase 2 clinical trials in Japan for acute myeloid leukemia and other blood cancers and also liver cancer. Dr. Neustadt said that while he is a fan of taking magnesium and that studies show that most people don’t get enough magnesium, but he does not recommend supplementing with magnesium for bone health, other than the 150 mg of magnesium that’s in the multivitamin that he has formulated. A healthy, Mediterranean diet includes adequate amounts of magnesium. Dr. Neustadt also does not recommend boron, since there are no studies showing that it reduces fracture risk.
27:11 Dr. Neustadt said that despite the fact that you often see magnesium, boron, vitamin C, and other nutrients in bone formulas, none of these have been proven to reduce fracture risk. He said that taking magnesium is a good thing, but there is no research showing that you need to take it in a 2 to 1 ratio with calcium to reduce fracture risk. Dr. Neustadt also said that there is no reason to take glucosamine sulfate or bone broth or collagen protein in order to potentially strengthen the collagenous part of bone, since there is no study showing that it decreases fracture risk. he also said that he would not use peptides, like BPC-157, unless there are studies showing a decrease in fracture risk. Studies that show increased bone density is not enough. We need studies to show that there is a reduction of fracture risk.
32:57 We know that estrogen is protective of bone and while there is some research showing that taking estrogen or selective estrogen response modifiers, like Evista, can reduce fracture risk, there are some concerns about using them in terms of cancer and heart risk.
33:51 Since there are such problems with bisphosphonates, salmon calcitonin can be used to help patients heal from fractures. But it is not that effective as a long term solution to reduce fracture risk.
34:15 One thing to consider is that heavy metals may be stored in bones, so if you are working with a client to reduce heavy metals and they are losing bone, they may be liberating more metals into the blood. So if you are treating a patient for heavy metals with a Functional Medicine approach, you may want to make sure they are in state of bone stability or you should incorporate a bone building protocol into your treatment.
35:45 According to Dr. Neustadt, the best type of diet for increasing bone density is the Mediterranean pattern of eating (the Mediterranean diet). This diet is high in whole grains, lean proteins, green, leafy vegetables, legumes, fish, olive oil, etc. Dr. Neustadt is not a big fan of drinking milk and eating dairy, as there are many allergies to dairy and there are issues with growth hormone in the dairy. You should try to consume 30 gms of fiber per day. You should also eat organic to avoid glyphosate and pesticides.
40:37 The best type of exercise to improve bone density and prevent fracture is exercise that improves your balance and prevents falls, according to the research. This can be yoga, Qi Gong, or going for a walk on uneven terrain. Balancing on one leg, the stork exercise, can be helpful, such as while you are brushing your teeth. Weight training has been shown to be helpful in stimulating the bones to become stronger.
43:44 The alkaline diet has been proposed to help bone density, since eating acidic foods could result in the body stripping calcium from the bones to alkalinize the system in response. Trying to create a higher pH, such as by eating an alkaline diet, drinking alkaline water, and/or including potassium citrate in your bone formula supplement as an alkalinizing agent, has been theorized to help with calcium balance and bone health. Dr. Neustadt said that he likes the alkaline diet only in the sense that it motivates people to eat a more plant-based diet. He said that studies do show that if you eat a lot of meat, you will excrete more calcium in your urine. Eating a lot of meat means that you are not eating a plant-based, whole foods diet, which is a risk for osteoporosis.
Dr. John Neustadt is the founder and Medical Director of Montana Integrative Medicine and he is the founder and President of Nutritional Biochemistry Inc. (NBI). He has written four books, including A Revolution in Health Through Nutritional Biochemistry, and he has published over 100 research review articles.
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Podcast Transcript
Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research, and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free eBook on my website by going to drweitz.com. Let’s get started on your road to better health. Hello, Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness Podcast, please go to iTunes and give us a ratings and a review. That way more people will find out about the Rational Wellness Podcast. And for those of you who don’t know, we also have a video version so you can go to my YouTube page, weitzchiro, and watch that and if you go to my website, drweitz.com, there will be a complete transcript and show notes.
Our topic for today is osteoporosis with Dr. John Neustadt. Osteoporosis literally means porous bones, and it refers to a condition in which the bones become fragile and the risk of fracture is increased. In fact, according to the National Osteoporosis Foundation, studies suggest that one out of two women and one out of four men over the age of 50 will break a bone due to osteoporosis. The most common sites of these fractures are at the hip, the spine, and the wrist. If you have osteoporosis and break your hip, there’s a 40% chance that you’ll be dead within six months. When you look at a bone density scan, if there is a T-score of 2.5 or greater, this is defined as, -2.5 or greater, this is defined as osteoporosis, and a score of -1 to -2.5 is termed osteopenia, which is a loss of bone, though not as severe as osteoporosis. Thanks to a new paper that Dr. Neustadt just sent me, we now know that even patients in the 35 to 50 year old range are suffering with bone loss. In fact, 28% of men and 26% of women in the U.S. in this 35 to 50 range have some loss of bone. As I understand it, one of the ways that we should understand osteoporosis is that throughout our lives we have a balance of both cells that build new bone, osteoblasts, and cells that clear out old, junky bone, osteoclasts. When we are younger, there’s a tendency for the osteoblasts to dominate and we tend to build more bone over the osteoclasts. And then when we get older, there’s a tendency for this to become reversed.
Dr. John Neustadt is the founder and medical director of Montana Integrative Medicine, and he’s the founder and president of Nutritional Biochemistry Incorporated, and also NBI Pharmaceuticals. He’s written four books, including A Revolution in Health Through Nutritional Biochemistry, and he’s published over 100 research review articles. Dr. Neustadt, thank you so much for joining me today.
Dr. Neustadt: My pleasure. So great to be talking with you.
Dr. Weitz: Excellent. So, why do you think we’re having such an epidemic of osteoporosis and osteopenia in the U.S. today?
Dr. Neustadt: Great question. It’s typically understood to be a disease of us getting older, and with the baby boomers getting to 65, 70 year old range the general population United States skewing older, it makes sense that as we get older and we are more likely to lose bone that the prevalence of osteoporosis and the risk of osteoporosis goes up. In fact, the fastest rate of bone loss for women is after menopause, the 10 years after menopause is the fastest, the time when women lose bone the fastest.
Dr. Weitz: And that’s because it’s related to estrogen levels?
Dr. Neustadt: Correct. Estrogen is considered anti-inflammatory. It also helps to build bone and maintain bone, and when that gets lost, you can get bone loss.
Dr. Weitz: Now, you know, we understand that women are programmed essentially for their hormone levels to drop after menopause a lot, their estrogen and progesterone levels, but men are not really programmed for that to happen, so why should men necessarily have a similar sort of risk as women?
Dr. Neustadt: Well they really don’t actually, and this new study that you quoted is new research. It’s groundbreaking research. I think there needs to be continuing studies, but it is incredibly alarming. The understanding currently of osteoporosis in men is that it affects about, you know, 20% of osteoporosis cases are in men, and 80% are in women-
Dr. Weitz: Oh, okay.
Dr. Neustadt: … so, disproportionately women are affected. This new research is very alarming though in that it’s showing first that bone loss is occurring much younger than we had anticipated and thought, and second, that it is occurring potentially at a rate much higher in men than we thought as well. What may be happening is that the rate of bone loss or the risk for osteoporosis, I’m speculating here, based on the research, may be similar for men and women. In the study the loss of bone was very similar in terms of the percentage of men and women in that 35 to 50 year old age group who had lost bone and became osteopenic, had pre-osteoporosis. And then as they get older and into menopause, that you get that drop in estrogen, what may be happening is then women actually start losing bone faster than men because they have, they’ve lost that estrogen, and at that point they’re actually outpacing the men in terms of the rate of the onset of osteoporosis. And we wouldn’t know if men are more susceptible that younger because all of the research to date has really been with osteoporosis, not osteopenia. And the screening guidelines the United States Preventative Task Force for osteoporosis doesn’t even recommend that men get screened for osteoporosis because it appears to be, based on the research that they looked at, so infrequent in men compared to women.
Dr. Weitz: Well, it may reflect a sedentary lifestyle and poor diet.
Dr. Neustadt: Absolutely, absolutely. And there is definitely that component to it. And I think it’s important to note that the most important risk with osteoporosis is not the low bone density. That’s a number on a test, or what’s called a surrogate marker. That’s not clinically the most dangerous thing about osteoporosis, or the most important that people need to worry about. The most important risk with osteoporosis is breaking a bone, as you correctly pointed out. If you fracture a hip and you have osteoporosis then there’s up to a 40% chance that you’re going to be dead in six months. If you happen to survive the first year, there’s actually a 20% chance that you’re going to end up in nursing home care and you’re going to suffer from chronic pain or other complications from that fracture.
So, anything that we do clinically and everything should be interpreted, both the testing and any recommendations, through that lens of how predictive is the test for predicting a fracture? And what does the research show in terms of what my doctor, or what I’m reading, is recommending I do? What does the research show in terms of its ability to actually prevent a fracture, not just change bone density, because since the 1990s we’ve known that a bone density test only predicts 44% of women who will break a bone and only 21% of men, which is shockingly low. It’s neither specific nor sensitive. The World Health Organization, the American College of Obstetricians and Gynecologists, anyone essentially that’s looked at the research has published position statements on this, have correctly concluded that fracture risk depends on factors largely other than bone density.
Dr. Weitz: So, what are some of those factors?
Dr. Neustadt: Great question. So, medications is a huge factor. We live in a completely overmedicated society. A lot of people don’t know and they’re popping these like candy and taking them for years and years, acid-blocking medications, the Protonix, the Prilosec, Zantac, those were never approved by the FDA for long term use, yet not only are they being prescribed for years for symptoms of acid reflux to suppress the acid, but now they’re available over the counter without a prescription. The research shows that after four years of taking them, over time, the risk continues to increase for osteoporosis and hip fracture, the most dangerous fracture, then after four years of taking them that the risk for a hip fracture increases by 60%.
Another common medication, Prednisone, oral Prednisone, can strip the bone of its minerals, calcium, and cause osteoporosis and increase the risk of fractures. Premenopausal Tamoxifen, if someone’s had breast cancer, been treated with Tamoxifen prior to going through menopause, that’s also a risk. There’s quite a list of medications that can cause that. The number one predictor of a future osteoporosis fracture is if you’ve had one already. So, if you have osteoporosis, you’ve had a previous fracture with osteoporosis, that’s the number one predictor of a future fracture. Medications are an issue. Other diseases that you may have, anything that causes malabsorption, like Crohn’s disease, ulcerative colitis, celiac disease, those are risk factors as well.
So, autoimmune diseases where there’s systemic inflammation, that’s a risk factor as well. And one of the, you know, sedentary lifestyle, not exercising, that’s a risk factor. Poor diet is a risk factor. There’s good research also showing in terms of risk factors for osteoporosis that what we want to prevent is falling because the number one event to occur just prior to breaking a bone typically is somebody falling, right? So, that’s where the sedentary lifestyle, the not exercising, comes in, that if somebody doesn’t have that balance and strength, then they’re more likely to fall and fracture.
Dr. Weitz: I’ve really been enjoying this discussion, but now I’d like to pause to tell you about the sponsor for this episode of the Rational Wellness Podcast. This episode is sponsored by Pure Encapsulations, which is one of the few lines of professional nutritional supplements that I use in my office. Pure Encapsulations manufactures a complete line of hypoallergenic research-based dietary supplements. Pure products are meticulously formulated using pure, scientifically tested and validated ingredients. They are free from magnesium stearate, gluten, GMOs, hydrogenated fats, artificial colors, sweeteners, and preservatives. Among other things, one of the great things about Pure Encapsulations is not just the quality products, but the fact that they often provide a range of different dosages and sizes which makes it easy to find the right product for the right patient, especially since we do a lot of testing and we figure out exactly what the patients need. So, for example, with DHEA, they offer five, 10, and 25 milligram dosages in both 60 and 180 capsules per bottle size, which is extremely convenient. And now, back to our discussion.
Dr. Weitz: You know, some people say that what appears to be a fall that results in a fracture is actually a pathological fracture of the hip that then results in a fall. Is that true or is that not really true?
Dr. Neustadt: So…
Dr. Weitz: Does that occur in some cases?
Dr. Neustadt: Yeah, the only cases where it’s really noteworthy is when people are taking bisphosphonate medications, right? It’s pretty rare unless you’re running, you have really weak bones, you come down so hard, but most people who fall, they lose their balance.
Dr. Weitz: Okay.
Dr. Neustadt: There’s no evidence to my mind. It’s sort of a chicken and the egg thing, what came first? It is understood that typically a fall precedes a fracture, and when that doesn’t happen, when the fracture happens first, what we’re looking for is medication-induced fractures, like if somebody is taking Fosamax for example, and that provides the pattern of fracture in a bisphosphonate break is a very specific pattern of fracture, and it’s a non-traumatic fracture so that can be differentiated.
Dr. Weitz: So, let’s clarify for people who are listening. Bisphosphonates are a classification of drugs that are prescribed for osteoporosis, correct?
Dr. Neustadt: That’s correct. They’re the most prescribed medication. They go by names of Fosamax, Zometa, for example. And like anything, the end goal, hopefully the end, the goal clinically is to reduce fractures, so the question is well, how much do these reduce fractures? The bisphosphonate category medications reduce fractures about 45%. Those are hip fractures with, I mean, vertebral fractures. Vertebral fractures can cause pain, but they’re not going to kill you. It’s the hip fractures that kill you. What’s been shown is Fosamax actually doesn’t even prevent what’s called a primary hip fracture. If you’ve never had a fracture before, it has not been shown to actually prevent a first fracture. And paradoxically, which I think is a little insane, that even though it’s rare, these medication are supposedly are supposed to prevent a fracture actually in rare cases, actually increase people’s risk for fracture. Not something we really want to do clinically.
Dr. Weitz: Like unusual fractures like femur fractures?
Dr. Neustadt: Correct. It’s called a unicortical break in the femur. Non-traumatic so there are cases in the medical literature of some woman actually, she was watering her plant, she’s on a stepstool and she just, she stepped down, she didn’t fall, she stepped down and twisted a little bit, and her leg just broke. And what happens when somebody is on the medication, and it breaks, it actually reduces their ability to heal from that, so it takes them longer to heal.
Dr. Weitz: Now can you explain how these bisphosphonates work, the mechanism of action?
Dr. Neustadt: Yes, they poison the osteoclasts. So, as you mentioned, there are two main cells in the bone, and, osteoblasts and osteoclasts. Osteoblasts build bone, osteoclasts break bone down. It’s a process called bone remodeling. And it’s important, it’s necessary. It has to be in good balance to break down old, used up bone and build new fresh bone to maintain healthy bones. That’s important. And what the bisphosphonates do is they poison the osteoclasts so the osteoclasts stop working and so you get a, the osteoblasts keep working and they keep building up bone but it’s abnormal bone, it’s weaker bone.
Dr. Weitz: You’re not clearing out the old, junky bone that should be cleared out to make stronger bone.
Dr. Neustadt: Correct.
Dr. Weitz: Now I’ve heard you talk about the fact that to prevent fractures, you mentioned the fact that bone density tests are not the most accurate tests and that’s because there’s a flexible part of the bone, right, that’s not-
Dr. Neustadt: Correct.
Dr. Weitz: … measured by the density. Can you explain what that flexible part of the bone is?
Dr. Neustadt: Absolutely. It’s the connective tissue in bone. So, bone is a tissue and like all tissues in the body, it’s made up of different substances. The bone density test only measures the mineral content of the bone. The minerals in the bone give bone its hardness, but there’s collagen, bone collagen, that gives bone its flexibility and actually gives bone what’s called its quality, its ultimate strength. If you were to take, and in fact when I was in medical school my histology class, the professor soaked a chicken leg, a chicken bone in acetic acid, in vinegar, and what that does it strips all the minerals away from it. And when all the minerals are gone, all that’s left is the collagen, the connective tissue. And he brought it in, and it’s like it’s a rubber chicken bone. It flexes, it bends, but it doesn’t break. And so that bone collagen, that connective tissue, is crucial and that’s not measured on a bone density test, nor is it taken into consideration typically in the conventional approach to looking at bone health and treating osteoporosis.
Dr. Weitz: So, if bone density tests don’t tell us about the true ability of a bone to resist fractures, are there any tests that do? What about urinary tests for bone resorption markers? What about measuring serum osteocalcin or undercarboxylated osteocalcin?
Dr. Neustadt: Great question. So, I want to make sure that I’m very clear in what I’m saying, that I don’t completely discount a bone density test. It does have some predictive value, but I think it’s important to put it in its proper perspective and place. It’s one piece of the puzzle. It’s one piece of data to consider, but most times when people come to me with their bone density test, there’s a lot of anxiety. They’ve got the diagnosis of osteoporosis. They’re very scared, and that’s all they’re focusing on. So, it’s important just to step back, and I think put it in its proper perspective, that it is one piece of the puzzle, and by no means is it the most important piece of the puzzle.
Yes, there are other tests that can, that are, again are what’s called surrogate markers. They’re markers that can look at different indicators of potential collagen or connective tissue health in the bone. They go by names that you said, osteocalcin or undercarboxylated osteocalcin, N-telopeptide, which is NTX, or CTX is another one, C-terminal peptide. And the challenge with those and why I don’t test those anymore is because there are no perspective studies showing that changing that value actually changes fracture risk. And in fact, with the undercarboxylated osteocalcin there was an animal study done some years ago in mice, in rats, where there was what’s called a wild type, just a normal rat that produced normal amounts of osteocalcin, and there was a genetically altered rat that was created that didn’t produce the osteocalcin. And after six months the rats that did not have the osteocalcin actually had stronger bones.
And it just shows that the story that we’ve learned about, you know, one marker leading, and one result is maybe too simple when it comes to bone, and we need to look a little more holistically. And why I don’t test is because is doesn’t, the only reason we should test any patient and run any test if it’s going to change our approach to treatment. And what I’ve learned over the years and working with thousands of patients, and doing my research, and lecturing and digging into the research, is that none of those tests except a bone density test will change my recommendations in terms of my approach.
Dr. Weitz: One of the companies is offering the undercarboxylated osteocalcin as a functional measure of vitamin K status.
Dr. Neustadt: Yes, that is a functional measure of vitamin K status, because vitamin K is required to carboxylate it.
Dr. Weitz: So, is it valuable for that purpose or is it valuable to measure serum vitamin K and do you also monitor vitamin D levels?
Dr. Neustadt: So, I do monitor vitamin D levels. I don’t typically monitor vitamin K levels. If there is, if they have osteoporosis, they come in with a diagnosis of osteopenia and osteoporosis, and by the way why osteopenia is for me such a huge red flag with that research that we talked about is because there was two studies that came out years ago that showed that people with osteopenia are actually at higher risk for fracture than people with osteoporosis.
Dr. Weitz: Really? How can that be?
Dr. Neustadt: Well that’s a great question, and people ask me that a lot. I don’t have a definitive answer. I think that there are a couple different potential answers. One is people may not be taking it as seriously. They get the diagnosis of osteopenia so maybe they’re not as protective with their bones, they’re not as proactive with their diet and exercise and maybe dietary supplements, or medications if that’s indicated, than people with osteoporosis are. So, that’s one potential explanation. I think that’s probably the simplest explanation, but I don’t know for certainty that that is the correct one. Nobody has really teased that apart. But with respect to testing, if somebody comes in with osteoporosis I don’t really, the only thing that I would test is vitamin D to see if I need to supplement at a level much higher than I normally would. But vitamin K I don’t test because what I go off of, what do the clinical trials show, are the nutrients that people can take that have been shown consistently to reduce fractures?
So, there are four nutrients that have been shown to reduce fractures and only four in clinical trials. So, calcium and vitamin D have been shown to reduce fractures about 20%, which is okay. The strontium has been shown to reduce fractures about 45%, which is no better, no worse than Fosamax, and I’m not a fan of using strontium as a first line, and I can go into that a little bit if you want after this, I talk about the next nutrient. But my first line therapy is a specific form of vitamin K called MK-4–45 milligrams per day. That’s been approved as a medication in Japan since 1995 for the treatment of osteoporosis and bone pain caused by osteoporosis. There have been over 7,000 volunteers studied and followed for up to eight years on that dose and higher. People with postmenopausal osteoporosis, osteoporosis from medications like Prednisone, and bone loss in children, people with autoimmune diseases and bone loss, and it’s consistently shown that not only can it stop and reverse bone loss as indicated by a bone density test, but again, that’s not the most important clinical thing, it’s does it reduce fractures? But repeatedly it’s been shown to reduce fractures by over 80% when combined with the calcium and vitamin D. So, my go-to is that MK-4. There are different forms of vitamin K, but it’s only the MK-4 form of vitamin K that’s been shown to reduce fractures. All forms of vitamin K will change that osteocalcin marker blood test, but again, that’s not the most important thing clinically, it’s what’s been shown to reduce fractures. And it’s only that MK-4 form that’s been shown to reduce fractures and there are over 25 clinical trials on osteoporosis and five of them specifically looked at fracture reduction as the endpoint that they were evaluating.
Dr. Weitz: The use of the MK-7 version of vitamin K2 is much more common, more popular in the U.S. right now, and this may be since serum levels of vitamin K stay elevated longer after consuming MK-7 than MK-4. And since MK-7 is converted into MK-4, shouldn’t taking MK-7 be as effective as MK-4?
Dr. Neustadt: So, great question. First of all, MK-7 is not converted to MK-4. Vitamin K1 is converted into MK-4 in the body.
Dr. Weitz: Okay.
Dr. Neustadt: The MK-7 is not produced by mammals, humans. It’s produced by bacteria. So, gut bacteria will produce some amounts of MK-7 and then it gets absorbed into our bloodstream.
Dr. Weitz: Okay.
Dr. Neustadt: Vitamin K1 can be converted through a specific enzymatic pathway in our body into MK-4 which then gets stored in different tissues in the body throughout the body. I’ve heard that argument before that MK-7 lasts longer in the body. It’s got what’s called a longer half-life, therefore it must be superior, must be better, but again, is that the most important thing with osteoporosis? The half-life of a substance. If that were the case then Fosamax would be the best thing to take because it’ll stay in the bone for years and years. No, the most important thing is does it reduce fractures. And again, MK-7 has never been shown as an endpoint in a clinical trial to reduce fractures. And they are different molecules. They are both vitamin K, but vitamin K is a category, and as different molecules they have a little bit different effect on the body.
MK-4, for example, has been shown as to have anti-cancer effect that MK-7 does not have. In fact, they’re up to phase two clinical trials in Japan with MK-4 45 milligrams and up to 135 milligrams per day for acute myeloid leukemia and myelodysplastic syndrome, blood cancers, also liver cancer. And MK-7 in contrast has been shown, if someone were coming to me and says, “I have coronary artery disease. I’ve atherosclerosis,” and that’s all they were worried about, “Should I take MK-4 or MK-7?”, I would tell them to take MK-7 because the research supports MK-7 more than MK-4 for being able to potentially promote arterial health and decalcify arteries, but with respect to bones and osteoporosis and fracture reduction, the research overwhelmingly supports MK-4.
Dr. Weitz: Wow. So, if we really wanted a comprehensive anti-aging program, we should probably be taking K1, MK-4, and MK-7.
Dr. Neustadt: You could, but there are other nutrients. You know, the anti-aging program-
Dr. Weitz: No, I know. Just in terms of the vitamin K part.
Dr. Neustadt: Yeah, it’s a yes. You could, but frankly I think that it’s, to get the clinical doses of all of that gets very expensive.
Dr. Weitz: Right. So, in terms of supplementing for osteoporosis, you mentioned taking the MK-4, calcium, and vitamin D.
Dr. Neustadt: Correct.
Dr. Weitz: What level do you try to get the vitamin D level up to? Do you try to get it up to 60 to 80? What’s your-
Dr. Neustadt: I love it. Anything above 60 I think is great. Yeah.
Dr. Weitz: Okay. What about adding magnesium? What about adding boron? What about adding strontium, vitamin C, antioxidants?
Dr. Neustadt: Great questions. Great, great questions. So, you find a lot of those in bone health supplements. And frankly you find them in multivitamin and mineral supplements too and in a good high quality vitamin and mineral supplements those nutrients should be there in adequate amounts for broad spectrum support.
Dr. Weitz: But you don’t get a lot of magnesium in a multi really.
Dr. Neustadt: Depends on the multi. The one that I created has 150 milligrams of magnesium per serving. So, I don’t know if that’s a lot to you or not.
Dr. Weitz: I guess it’s not, to me, no.
Dr. Neustadt: Right. So, it depends on what the target is. But here’s the bottom line, the most important question is has magnesium, boron, the other nutrients that you mentioned, have they-
Dr. Weitz: Strontium.
Dr. Neustadt: Well, strontium I said has been shown to reduce fractures, but have magnesium and boron, or other vitamins, have they ever been shown to reduce fractures?
Dr. Weitz: Right.
Dr. Neustadt: The answer is no. They’ve never been shown to reduce fractures. And so for me clinically when I’m working with patients and wanting to use what I think is the highest evidence, which is the randomized, you know, clinical trials, and we can get 80 plus percent fracture reduction verified in multiple clinical trials just with the combination of MK-4, 45 milligrams a day, calcium and vitamin D, and I’m targeting bone health and just osteoporosis. As an osteoporosis supplement, that’s what I would use, and in fact that’s what I created because I needed it to help my patients, and I couldn’t find one that works so I created the product. I couldn’t find, not one that worked, I couldn’t find one that had the nutrients, the combination, the dose of nutrients shown in the studies to work, so I created it. But, and then the other nutrients that you mentioned, if, I’m a big fan of magnesium, huge fan of magnesium, and I think and the research has shown that, you know, over half of the population don’t get enough, don’t consume adequate magnesium in their diets, that having it as a supplement is important but if we’re just targeting osteoporosis, there’s no research showing that it reduces fracture risk. And so, I like to move people more towards a whole foods diet, magnesium, green leafy vegetables. Every center of the chlorophyll atom has a molecule of magnesium in it so that whole foods, Mediterranean style dietary pattern whole foods diet, very rich in all those nutrients we’ve just mentioned except for the strontium.
Dr. Weitz: So, there’s no reason to get two to one ratio of calcium magnesium or anything like that?
Dr. Neustadt: So, there’s no study showing that that actually affects absorption that I’ve ever seen. I keep asking people please send me a citation, send me a study. For me, it’s reached the status of myth out there and I’ve yet to have anybody actually be able to send me a study. It’s theoretical that one may compete with the other or you need them in a certain ratio, but in terms of fracture reduction to get that 80 plus percent, it was MK-4, 45 milligrams a day, vitamin D, and calcium, and that’s it.
Dr. Weitz: If the key is the collagenous part of bone, if there’s going to be more about supplements, is there any benefit in taking things that are known to help with collagen like glucosamine sulfate, bone broth, collagen protein?
Dr. Neustadt: Great question. So, for me the question I’m going to always go back to and that I really work with a lot of people that, osteoporosis-
Dr. Weitz: Let me guess, is there any study showing that they decrease fracture risk?
Dr. Neustadt: That’s exactly right. That’s it. It’s not complicated in my mind. What are the studies showing it reduces fracture risk? And dietary supplements and taking supplements can get very expensive for people, and so what we know in terms of maximum fracture risk reduction are those three nutrients that I mentioned, medications if necessary. I’m not opposed to them but I think the best fracture reduction on a medication is on Forteo, which is only available by injection, but, you know, what has been shown to reduce fractures, or falls, and fall related injuries in osteoporosis? It’s diet, exercise, MK-4, 45 milligrams a day, calcium, and vitamin D, and strontium, but I don’t like to use strontium.
Dr. Weitz: Peptides have become very popular, and there’s one called BPC, Body Protective Compound-157 and that’s been shown to stimulate bone healing at least in some of the animal studies.
Dr. Neustadt: I think that’s wonderful preliminary research and I’m definitely open to learning of new things that actually work but as a clinician, I’m going to go back to that same question, you know, just because it’s in an animal study doesn’t mean it translates into humans, and we see that over and over in medical research. And what happens is you see a lot of these companies that are coming out with these raw materials like AlgaeCal, for example, or the MK-7, and they’ll have studies and every time the study will report, you look at it, it’ll report increase in bone mineral density, increase in bone mineral density. Well ask the question has it been shown to reduce fractures? Because we know that a bone mineral density test only predicts 44% of women and only 21% of men who will fracture.
Dr. Weitz: Since estrogen is protective of bone, should postmenopausal women take bioidentical estrogen?
Dr. Neustadt: I think that if they are showing symptoms of hot flashes and insomnia and other symptoms of low estrogen and issues with that then that is a good clinical indication to potentially supplement them. There is research taking estrogen and what are called selective estrogen response modifier, those category of medications, Evista, for example, is one of them, can reduce fracture risk. So, should they take it? There can be some risks with taking those so that would be something to be decided only in consultation with their healthcare provider who knows their medical history and their risk profile.
Dr. Weitz: Since there’s such a problem with these bisphosphonates, what about salmon calcitonin?
Dr. Neustadt: You know, salmon calcitonin I’ve used to help people heal from fractures within the elderly, and it’s got some good research on it, but as a longterm solution, the fracture reduction is not great.
Dr. Weitz: Okay. One thing I thought that was interesting I heard you say in one of your talks, this is a little bit of a tangent for those of us in a functional medicine space is that if you have a patient who’s in a condition where they’re losing bone, we may see an increase in heavy metals in the blood since some of these metals tend to get stored in the bone, and I think that’s pretty interesting because a lot of us are dealing with chronic patients, some of whom have heavy metal toxicity, and we may find that sometimes their heavy metal toxicity continues even though we’re using some protocols that should be reducing their heavy metals, and we may not be considering the fact that if they’re in a state where they’re losing bone, they may be continuing to liberate more heavy metals into their bloodstream, and so, you know, if we’re dealing with a patient like that, especially with a postmenopausal woman, we might consider the importance of trying to get their bone situation stabilized.
Dr. Neustadt: Absolutely. Absolutely. So, and there are risks, you know, for osteoporosis and if somebody does have one of those risk factors even the U.S. Preventative Task Force says any, you know, women under 65 who are premenopausal with risk factors for osteoporosis should be screened for osteoporosis. So, they don’t really, on their radar it’s not the heavy metal toxicity but definitely on mine it is and it sounds like it’s on your radars as well.
Dr. Weitz: Yeah. So, what’s the best kind of diet for increasing bone density?
Dr. Neustadt: So, the best, over 60 years of research without a doubt the Mediterranean pattern style of eating. And I really, it’s something, it’s referred to as a Mediterranean diet, but I really want people to understand it’s not as if you’re going on a diet, it’s an eating pattern. It has its own food pyramid, and it’s really basically a whole foods diet. Getting those nutrients that we talked about, the minerals, the vitamins, from whole plant foods. Very high in whole grains and at the base of the pyramid, vegetables, like I said, whole foods. As you go up, lean proteins, you know, you’ve got legumes in there, chicken and fish maybe weekly. It’s the opposite of the standard American diet which is a lot of red meat and highly processed foods. And in the Mediterranean eating pattern red meat is consumed, you know, less than weekly, maybe once every couple weeks, and all in moderation. Water, ample water, exercise, it’s really an eating pattern but it’s also a lifestyle.
Dr. Weitz: It’s kind of hard to know when you start reading all the articles on the Mediterranean diet, and don’t get me wrong, I’ve seen a lot of positive studies, but there’s a lot of confusion from study to study exactly what constitutes a Mediterranean diet. You mentioned whole grains, you know, how much pasta, how much bread is there? People talk about legumes, you know, is cheese part of it? You know, olive oil, red wine. I’m not so sure it’s that clearly defined a diet, but, you know, I get your general point about it.
Dr. Neustadt: I totally agree with you, and you hit such an important point of how confusing this research can be for somebody. So, here’s my, my overall emphasis is that typically people when they come to me and probably you as well, you know, where they’re at in their eating is really far from where it should be. And a lot of it is just starting, people becoming aware of it. And so the first thing I do with people is I have them quantify. I break it down to the number of grams of total fiber and the number of grams of protein they’re getting a day. And that total fiber needs to come from whole foods, not a supplement. So, that would be the green leafy vegetables, that could be some legumes, and I shoot for a minimum of 30 grams of total dietary fiber a day, and they have to quantify it. And for a couple days without changing their diet, and same with their protein requirement is calculated based on their body weight. And so, over six weeks or so I work them to transition into eating more of a whole foods diet. I’m not a fan of dairy, as you and I discussed prior to the podcast. The biggest reason is I don’t think it aids a great source of nutrients, but there’s so many hormones in there that I don’t think are real, they’re not healthy. And a lot of people react to dairy. They can have allergies to them that they’re not even aware about. They get stuffy nose, post-nasal drip, gas and bloating, that sort of thing.
So, I’m not a fan of dairy, and the dairy in Europe and the Mediterranean’s very different. They have a different regulatory environment for the hormones that they allow, what they allow on their crops. And our crops are, unless it’s organic, are quite poisons with glyphosate pesticides and recombinant growth hormones in the beef, and it gets into the dairy, and so I counsel people eat as organic as possible if you can. If you feel that you can’t afford 100%, you know, stay away from what’s called the dirty dozen, the 12 most pesticide-laden fruits and vegetables. And if you can see what it was-
Dr. Weitz: For those of you who don’t know, that’s from the Environmental Working Group publishes a list on dirty dozen of the fruits and vegetables that are most likely to have a lot of pesticides.
Dr. Neustadt: Exactly. Exactly. And, you know, and then there are just some general rules of thumb that I guide people on. If you can see, look at it and know where it came from, it’s a whole food.
Dr. Weitz: What about soy? Should women be eating soy?
Dr. Neustadt: In moderation I don’t have a problem with it. I’m a big fan of moderation. Like, if somebody wants to have a little dairy every once in a while, okay. I’m not really fanatical about most things.
Dr. Weitz: Could soy be beneficial because of phytoestrogenic effect?
Dr. Neustadt: It can actually. It can. Again, it’s never been shown to reduce fractures, but yes, soy does have some benefits. But then it is the question of how much do you really need to eat to get those benefits?
Dr. Weitz: What’s the best type of exercise for improving bone density, improving bone, preventing fracture of bones?
Dr. Neustadt: Yeah, great question. The best exercise is one that helps people improve their balance to reduce their risk of falling and fall related injuries. So, a lot of people think that when they get the diagnosis, or they got to start exercising, they have to go to the gym, they’ve got to start pumping iron. And that’s what people want to do, great. But, for a lot of people who don’t want to do that it becomes an impediment to them doing anything because they’re under that impression that that’s what they need to do. But, the research shows that anything you do to improve your balance will reduce the risk of falls and fall related injuries. So, that can be gentle yoga, that can be Qi gong, even going for a walk on uneven terrain where you’re walking up and down, you know, over a curve, you know, anything that sort of improves that balance.
And I love and I read a blog on it what’s called the stork exercise. I love things that people can do in their house. There are ways to work exercises into people’s daily routine so it just becomes part of their life. So, the stork exercise, while you, you know, storks, they stand on one leg, while somebody brushes their teeth, and brushing your teeth should be two minutes a day. While you’re brushing the bottom teeth for a minute in the morning you stand on one leg and you can kind of hold the sink if you want a little bit to balance yourself, but try not to use it as a crutch, not too much. And you stand on one leg in the bottom teeth for a minute and you time it, and then when you switch to the top teeth, if you’ve got a Sonicare or something it times it for you. Switch to the top teeth, you switch legs. And you do that twice a day. And that’s been shown to improve balance. They’re just little things that people can do.
Dr. Weitz: But, hasn’t resistance training, weight training, doesn’t that stimulate the muscles to pull on the bones which causes the bones to become stronger?
Dr. Neustadt: Absolutely. Weight training and that sort of training has been shown to improve bone density and absolutely, it has benefits. And I do encourage people to do that. It can be isometric. It doesn’t necessarily have to be weights. It can be somebody’s body weight as well. But I’m also a fan of trying to meet people where they’re at, and not, it’s, treating the individual because there’s a lot if somebody doesn’t want to go into a gym or maybe they can’t afford it or it doesn’t fit into their day or they’re not motivated enough to do it, there are ways to get them to start doing things proactively that can be incredibly beneficial and then maybe over time, maybe they get the exercise bike and they want to do a little bit more. It’s what I hope. And they can always build on those successes.
Dr. Weitz: Great. I think that’s all the questions I have. Any final thoughts you want to leave our listeners and viewers with?
Dr. Neustadt: This has been fantastic, lot of fun talking with you, and hopefully your viewers have gotten a lot out of it. I think it really boils down to that one question I kept going back to, and I try and educate people over and over. The most important question, whether, if it’s a test, to ask the clinician is, how predictive it this that I’m going to break a bone? How well does it predict my fracture risk?
Dr. Weitz: Right. Oh, you know what, there is one more thing I wanted to touch on.
Dr. Neustadt: Sure.
Dr. Weitz: The idea of trying to eat a more alkaline diet.
Dr. Neustadt: Yeah. So, I’m a fan of that only in the sense that what is an alkaline diet? It’s a whole foods diet. It’s a whole foods plant-based diet. So, if that’s what people like and it’s really popular. They like that you can test it at the pH strip. You can test your urine to see if it’s getting more alkaline. I think that’s great. Whatever’s going to motivate somebody to take charge of their health, to take more responsibility and get excited about eating well. I think it’s fantastic.
Dr. Weitz: But is there really something to, if your body is more acidic, you’re going to strip calcium off the bones to balance out the pH in the blood, is there anything to that?
Dr. Neustadt: So, there’s research that’s been shown looking at people who consume meat, and meat tends to be rather acidic, and that’ll strip, that’ll increase calcium excretion in the bone.
Dr. Weitz: Okay.
Dr. Neustadt: But that’s very different from saying you’ve got increased calcium, I mean sorry, it’ll increase calcium excretion in the urine. So, you’re peeing out calcium. But it’s very different to say, there haven’t been studies that I’m aware of at least that make that next connection to say, okay, people eat an acid diet. Their calcium is increasing in their urine. Well, is that because the calcium that they’re absorbing, they’re just peeing more of it out, or are they actually stripping it from the bone, and is it creating osteoporosis? So, if you’re eating that way, regardless of if people want to characterize it as acid or not, which it is if you’re eating a high meat diet. The research is very clear. That’s not a plant-based whole foods diet. And that is a risk for osteoporosis. Whether the mechanism is the acid or not, I’m not sure. Maybe there are people who are more expert in that that can more definitively answer that question, but the bottom line is that is a dietary pattern that is not a whole foods plant-based diet that has been shown to create osteoporosis, and it could be because of the acid, but it could also be because of nutritional, mineral deficiencies.
Dr. Weitz: And you know, besides meat, the other area of controversy, you keep mentioning whole food plant-based diet, or, is like grains and beans.
Dr. Neustadt: Correct.
Dr. Weitz: You know, grains generally are considered to be acidic.
Dr. Neustadt: Correct. Everything in moderation. It’s a balance. I’m not saying eat grains with every meal. I’m not saying eat that, that’s the majority of your meal, or majority of your nutritional source. It should be a balanced diet. So, for me, you know, I love, you know, I’ll have, you know, spinach and green leafy vegetables, and a rainbow of colors from bell peppers and carrots and you know, other fruits and vegetables, and then maybe I’ll also have on there some, a sweet potato, for example, for my starch. Not always a grain. There are other ways to do it. And a lean protein like fish, like soy, tofu or something like that. There are different ways. But there’s also protein and vegetables, and I think people lose sight of that. Vegetables do have protein in them.
Dr. Weitz: Okay. Good, good, good, excellent. So, yeah, I think you’ve provided us with a lot of great information to think about in terms of improving our bone density, reducing our risk of fractures, and helping those of us who are practitioners for helping our patients to reduce their risk of fractures. What’s the best way to get ahold of you?
Dr. Neustadt: The best way would be through my website, nbihealth.com. NBI stands for Nutritional Biochemistry Incorporated so it’s nbihealth.com if they want to reach me. There’s a contact forum or a toll-free number on there, and they can reach me through the forum or my staff can always forward any messages to me from-
Dr. Weitz: Are you still seeing patients?
Dr. Neustadt: I do all pro-bono consulting work now by phone with people.
Dr. Weitz: Oh, okay.
Dr. Neustadt: I’ll see people by phone, maybe two or three a week, to help them, but they’re not officially my patients. I help them understand what questions like this they can go back and ask their doctors. What tests, maybe they’re missing. I synthesize things that have been going on with them, help them understand, reframe what’s going on. I’ll recommend dietary supplements, lifestyle, diet, have them talk about medications or testing further with their healthcare provider.
Dr. Weitz: Great. Excellent. Thank you, Dr. Neustadt.
Dr. Neustadt: Thank you so much.
